Nova Scotia's. Opioid Use and Overdose Framework

Nova Scotia's Opioid Use and Overdose Framework

Crown copyright, Province of Nova Scotia, 2017 Nova Scotia s Opioid Use and Overdose Framework Department of Health and Wellness July 2017 ISBN: 978-1-55457-748-4

What We Know: The Scope of the Problem in Nova Scotia Canada is the middle of a public health crisis of opioid use and overdose. Across the country, governments at all levels and organizations from various sectors are taking action. There has been much media coverage about illicit fentanyl and overdose deaths; however, this is only part of the issue. There are actually two distinct but related aspects to the opioid crisis. The immediate issue is the illicit production and distribution of synthetic opioids. Synthetic opioids, such as fentanyl, are highly potent and relatively easy and inexpensive to produce. Fentanyl and other opioids are often cut into other pills or powdered street drugs in varying sometimes deadly amounts. Canada has seen an increase in opioid overdoses and overdose deaths associated with the arrival of illicit fentanyl in street drug supplies. Criminal organizations have become the main source of illicitly produced fentanyl in Canada. At the same time, there is a longer standing problem of the over-prescription of opioids for pain treatment. The prescription of opioids within the Canadian health care system over the past 20 years has created large numbers of people for whom the legitimate use of these drugs has become problematic. Nova Scotia doesn t have the number of overdoses and overdose deaths being experienced in British Columbia and Alberta, but the problem is moving east and we need to respond to prevent a bigger crisis. From 2011 to 2015, Nova Scotia averaged 60 overdose deaths per year from opioids alone, or in combination with alcohol, benzodiazepines and other prescription and/or street drugs. In 2016, there were 53 acute opioid overdose deaths with four involving illicit fentanyl and three involving U-47700, another powerful synthetic opioid sometimes in combination. In addition, illicit fentanyl was identified on multiple occasions in 2016 by police in Nova Scotia. The increased availability of illicit fentanyl will not only lead to more avoidable deaths, but also has an impact on emergency first responders and health care services. This is a complex issue and we must be thoughtful in our approach, taking care to understand the impact of our actions in a broader context. Significant consideration has been given to how we reduce the harm associated with opioid use, address illicit fentanyl in street drug supplies, and change opioid prescribing and pain management practices in a way that minimizes the the serious complications of opioid use including opioid-induced pain, opioid addiction, and diversion. Why We re Taking Action There are many different pathways to problematic opioid use and overdose, and people from all walks of life are involved. This includes street-involved opioid users who may have experienced adverse childhood experiences or trauma, young people experimenting with drugs, seniors who finds themselves dependent on painkillers prescribed after surgery, or an individual suffering with chronic pain from a workplace injury whose opioid use has progressed to addiction. These are our young people, our family members, our neighbours and our most vulnerable, and they live beside us in our communities. Part of our response to this serious public health problem is acknowledging that substance use and addiction are health and social issues, not criminal issues, and people struggling with addiction deserve to be treated with the same dignity, respect and compassion as any other person. Opioid misuse is a complex health and social issue with a multitude of contributing factors, including: > > social stigma related to addiction and mental health > > our cultural norms related to taking pills and to pain management > > aggressive and persuasive marketing of opioids by the pharmaceutical industry NOVA SCOTIA S OPIOID USE AND OVERDOSE FRAMEWORK 1

> > problematic opioid prescribing practices > > the training of health professionals in pain management > > poverty, homelessness and unemployment > > gaps in access to mental health and addictions treatment > > isolation and a lack of social connectedness > > family conflict > > the experience of chronic pain due to injury and illness > > trauma, including adverse childhood experiences How We ve Responded to Date In late October 2016, government established a provincial leadership committee, co-chaired by the Departments of Health and Wellness and Justice. The purpose of this committee, and the seven working groups reporting to it, was to develop Nova Scotia s Opioid Use and Overdose Framework. From November 2016 to January 2017, the committee identified short and long term actions for: monitoring and data collection, health promotion, harm reduction, naloxone access, opioid use disorder treatment, opioid prescribing, and law enforcement. In March 2017, government announced more than $1 million in funding to address the increase in illicit fentanyl and other synthetic opioids in Nova Scotia. This funding was used to expand access to life-saving naloxone, and to support harm reduction throughout the province through three community-based organizations: Northern Healthy Connections Society in Truro, Mainline Needle Exchange in Halifax, and Sharp Advice Needle Exchange in Sydney. An epidemiologist from the Public Health Agency of Canada was brought in to the Medical Examiner s Office on a two-year term, beginning mid-2016, to monitor, track and report on opioid overdose deaths in Nova Scotia. Nova Scotia is also part of the national response to the opioid crisis in Canada, attending the National Opioid Summit in December 2016 and participating in the national Special Advisory Committee on Opioid Overdose and Misuse, where there is a focus on developing a national approach to monitoring, plus sharing of best practices in areas such as harm reduction, access to naloxone, and treatment. While the focus so far has been on addressing the immediate impacts from the increased availability of illicit opioids, as we move forward, we need to turn our attention to the various and longer-term issues involved with opioid use disorder treatment and opioid prescribing practices. What s in our Framework This framework outlines the key areas of focus to effectively respond to problematic opioid use and overdose in Nova Scotia. To fully understand the situation in Nova Scotia, and to further develop and implement the actions in this framework, we will need to collaborate with and meaningfully engage a range of stakeholders and communities. Areas of focus: 1. _Understanding the Issue Engagement: Engaging with stakeholders and communities is a key part of developing and implementing a response to opioid misuse and overdose. Engagement will contribute to our understanding of opioid use and overdose in Nova Scotia and help us develop relevant and culturally appropriate responses. The leadership committee will: > > Ensure that the appropriate stakeholders inform the continued development and implementation of the framework; and > > Convene a First Voice Advisory Group made up of harm reduction organizations and front line workers who work with Nova Scotians who use illicit drugs. This advisory group with lived experience will contribute its expertise and advice to the Leadership Committee on Opioids. NOVA SCOTIA S OPIOID USE AND OVERDOSE FRAMEWORK 2

Surveillance and monitoring: Enhancing surveillance, modelling and analytics, matched with qualitative analysis, are significant gaps for many, if not most, health issues in Nova Scotia. We have built capacity for a timely assessment of opioid overdose death to help prepare the province in case of a growing crisis but there is more to learn and understand. Building a robust drug surveillance and monitoring system will help us understand opioid use in Nova Scotia, enhance evidence-informed prevention and intervention efforts, and help identify emerging trends so we can respond quickly to emergencies. Our framework includes: > > Developing a process for sharing timely, local-level data from Emergency Health Services and hospital emergency departments on all acute drug overdoses > > Participation in the development and implementation of a national epidemiological study on opioid use and overdose > > Moving beyond monitoring of overdose deaths to explore what other knowledge is needed to support the actions in this framework, and to monitor its effectiveness (for example, tracking the number of naloxone kits distributed, the number of people accessing treatment, wait times for treatment, etc.) 2._ Prevention Awareness and education: Public awareness and education activities can help shift cultural norms that contribute to opioid use and overdose. To ensure Nova Scotians are well informed on the risks associated with opioid use, our framework includes: > > Identifying opportunities to support public awareness and patient education activities led by Health Canada and monitor any need for provincial public awareness and education efforts Youth: Teachers and school communities play an important role in building resiliency and protective factors (e.g. school connectedness, availability of supports and services, literacy and problem solving skills, positive role models) that help mitigate risk. Nova Scotia has several existing initiatives that contribute to student health and wellness in the public school system, including curriculum, Health Promoting Schools, Schools Plus, and Youth Health Centres. Our framework includes: > > Enhancing efforts to promote student health by ensuring a focus on substance use prevention in these existing processes > > Continuing our work with partners and stakeholders on issues related to student health and wellness at the post-secondary level, including alcohol, opioids, and other problematic substance use Trauma-informed approaches: Trauma, including adverse childhood experiences, is a major contributor to mental illness, family dysfunction, and substance use, including opioid use and overdose. Much work has been done across Nova Scotia around trauma-informed approaches, and select health and social system care providers have been trained in this approach. This framework includes: > > Building on this work and exploring opportunities to bring trauma-informed approaches to broader, non-health care settings (e.g. schools, workplaces, housing, justice) and to the community level 3._ Harm Reduction Naloxone: Increasing access to naloxone (the medication that can rapidly reverse an opioid overdose and prevent death) is a critical component of an effective opioid response plan. To that end, this framework includes: > > Building on two successful pilot projects in Halifax and Cape Breton to make takehome naloxone kits available through a wide range of health care and community settings, including community pharmacies. NOVA SCOTIA S OPIOID USE AND OVERDOSE FRAMEWORK 3

Needle distribution and disposal: Currently, needle distribution and disposal services in Nova Scotia are delivered by community organizations that are under-resourced and have ever-increasing demand. A critical element of this framework includes: > > Ensuring sustainable funding for needle distribution and disposal services through Mainline Needle Exchange (Halifax), Sharp Advice Needle Exchange (Sydney) and Northern Healthy Connections (Truro) to support ongoing efforts to prevent the transmission of HIV and Hepatitis C, provide support for marginalized and vulnerable populations, and help maintain community health and safety Harm reduction models: Beyond the immediate action of stabilizing funding, there is also a need to review the current needle distribution and disposal services model and understand the relevance of safe consumption sites in Nova Scotia. These services are vital to ensuring Nova Scotians who use drugs remain safe from harms. This framework includes: > > Exploring other models of harm reduction in Nova Scotia, including needle distribution and disposal, and safe consumption sites 4._ Treatment and Prescribing Practices Treatment: While treatment options exist for opioid use disorder, there is a need to enhance system capacity to increase timely and equitable access to a continuum of services and supports for individuals and families experiencing harms related to opioid use. This framework includes: > > Expanding Pharmacare coverage of buprenorphine/naloxone (e.g., Suboxone) as an option to treat opioid use disorder for all ages > > Increasing capacity to manage opioid addiction and overdose in primary care and emergency programs, and providing the necessary supports to providers (e.g. information, skill-building, access to expert advice or referral) > > Expanding access to specialized NSHA-funded treatment programs Alternative pain management: Non-pharmacological treatments for pain (e.g. physiotherapy, occupational therapy, chiropractic care) are often discussed as part of the solution to lessen reliance on opioids. However, not all Nova Scotians can afford non-pharmacological treatments. To address this disparity, our framework includes: > > Working with partners to increase access to and affordability of alternative pain management, particularly for disadvantaged and vulnerable Nova Scotians > > Building on work already underway with the NSHA-led Provincial Pain Management Network to update the inventory of chronic pain services in Nova Scotia, strengthen links between primary care and pain specialists, and develop recommendations for best practices in chronic pain management Prescribing practices and provider support: Health professionals are at the forefront of the response to opioid misuse and overdose. Supporting providers to follow best practice guidelines on opioid use will help reduce inappropriate prescribing of opioids and support efforts to taper and care for patients on high-dose opioids. Establishing prescribing thresholds will help to control initial prescriptions and prevent overprescribing of opioids for acute pain, reduce the pool of unused medications available for diversion, and reduce the rates of dependence or addiction. The framework includes: > > Identifying and providing the supports necessary to implement new national guidelines on the use of opioids to treat chronic, non-cancer pain > > Establishing prescribing thresholds for the treatment of acute pain, and developing a special authorization process for prescriptions that exceed those thresholds NOVA SCOTIA S OPIOID USE AND OVERDOSE FRAMEWORK 4

> > Working with stakeholders to build the necessary knowledge and practice supports in primary care to address the treatment of opioid use disorder and to implement new prescribing guidelines, including appropriate tapering for existing pain patients 5. Criminal Justice and Law Enforcement Wellness and drug treatment court programs: Sometimes referred to as specialty courts, these programs use therapeutic, restorative approaches to support marginalized people who are criminalized because of their addictions. Therapeutic court programs address the root causes of offending behavior, and encourage plans that link people to services with the goal of promoting recovery and reducing the likelihood to reoffend. These court programs offer alternative sentences for people charged with crimes related to their opioid use disorder, while carefully managing potential risks to the public. There are various programs already in place in Nova Scotia, including a Mental Health Court Program and Drug Treatment Court Program in Dartmouth and Kentville, Wellness Courts in Port Hawkesbury and Amherst, and a Wellness and Gladue Court in the First Nation community of Wagmatcook. Our action framework includes: > > Exploring opportunities to expand wellness programs in the justice system Drug seizure information sharing: Our framework includes furthering our knowledge of illicit opioid availability in Nova Scotia by: > > Putting processes in place to allow information sharing on drugs seized by police to assist with provincial surveillance needs, including drug identification and hot spots Drug interdiction measures: Reducing the availability of illegal opioids is an important part of our framework. Measures are already in place to prevent drugs such as fentanyl from entering correctional facilities, and this framework builds on this work by: > > Ensuring ongoing maintenance and software upgrades to ION scanners, which are a non-invasive search tool for inmates, staff and visitors, as well as for incoming mail and parcels > > Investigating options to equip facilities with body scanning devices, which are a best practice standard in drug interdiction efforts > > Continuing to focus resources and investigative efforts on illicit opioids Occupational health and safety for first responders: Opioids such as fentanyl create challenges for law enforcement due to the occupational health and safety concerns and specialized training requirements needed to handle these substances. As in other jurisdictions in Canada, police in Nova Scotia have focused enforcement efforts on illicit opioids, and now have access to specialized Clandestine Laboratory Enforcement and Response Team resources through the provincial police to deal with illegal drug labs and hazardous properties. Some police agencies also use specialized forensic officers trained in handling hazardous materials. To support these ongoing efforts, our framework includes: > > Ensuring continued access to naloxone for law enforcement and first responders, including paramedics and community-based volunteer firefighters, to protect themselves and help overdose victims > > Continuing to work with partners and stakeholders to mitigate risk related to opioids, and providing information and training as well as take-home naloxone kits to offenders who use opioids when they reintegrate into the community > > Providing ongoing training and occupational health and safety education to investigators and first responders > > Ensuring that policies and personal protective equipment are consistent with best practice standards across the country NOVA SCOTIA S OPIOID USE AND OVERDOSE FRAMEWORK 5

Conclusion Opioid use and overdose is a complex issue, and addressing it will require strong communication and collaboration among stakeholders. We have made considerable progress already in Nova Scotia, particularly in terms of harm reduction and naloxone availability. Some of the measures outlined in this framework will proceed immediately; others will take time. We must be thoughtful and coordinated as we implement these actions to ensure we don t inadvertently do more harm. The success of this framework relies on addressing fundamental, long-standing issues in our health care system including building capacity in primary care, increasing access to mental health and addictions services, and shifting over-reliance on opioids to treat and mange pain. We know that experiences with trauma contribute to opioid use for many individuals. We must build systems and services that recognize the links between trauma, mental health and substance use. We cannot make progress on this framework without addressing the root causes of, and contributors to, opioid and other substance use. This is a critical element of keeping people healthy and preventing substance use in the first place. It also helps to reduce the stigma associated with substance use, addiction and mental health. We must go back to basics with a greater focus on creating healthy and supportive families and communities as the backbone of improving our collective health. These issues are all part of the overall transformation currently underway in the health system and Nova Scotia s Opioid Use and Overdose Framework reminds us to stay on course. Leadership committee and working group chairs Dr. Robert Strang, Chief Medical Officer of Health (co-lead) Roger Merrick, Director, Public Safety, Nova Scotia Department of Justice (co-lead) Kimberlee Barro, Executive Director, Health Promotion, Nova Scotia Department of Health and Wellness Dr. Matthew Bowes, Chief Medical Examiner, Nova Scotia Dr. David Butler-Jones, Senior Medical Officer, First Nations and Inuit Health, Health Canada Dr. Linda Courey, Senior Director, Mental Health and Addictions, Nova Scotia Health Authority Dr. Gus Grant, Registrar and CEO, Nova Scotia College of Physicians and Surgeons Samantha Hodder, Health Promotion Lead, Mental Health and Addictions, Nova Scotia Health Authority Elaine Holmes, Director, Communicable Disease Prevention and Control, Nova Scotia Department of Health and Wellness Bill Moore, Deputy Chief of Police, Halifax Regional Police (retired) Marlene Snowman, Chief Superintendent, Royal Canadian Mounted Police Dr. Andrew Travers, Provincial Medical Director, Nova Scotia Emergency Health Services (EHS) Beverley Zwicker, Registrar, Nova Scotia College of Pharmacists NOVA SCOTIA S OPIOID USE AND OVERDOSE FRAMEWORK 6